Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pediatric Diphtheria Workup

  • Author: Cem S Demirci, MD; Chief Editor: Russell W Steele, MD  more...
 
Updated: Mar 10, 2016
 

Laboratory Studies

Diagnostic tests used to confirm infection combine isolation of C diphtheriae on cultures with toxigenicity testing.

  • Bacteriologic culturing is essential to confirm the diagnosis of diphtheria.
    • In all patients in whom diphtheria is suspected and in their close contacts, obtain specimens from the nose and throat (ie, nasopharyngeal and pharyngeal swab) for culture.
    • Obtain a clinical specimen for culture as soon as possible when diphtheria (at any location) is suspected, even if treatment with antibiotics has been initiated.
    • Obtain specimens from the membrane as well as from the nose and throat. If possible, swabs also should be taken from beneath the membrane.
    • Alert the laboratory to the suspicion of diphtheria because isolation of C diphtheriae requires special culture media containing tellurite. C diphtheriae may be grown on various selective media, including tellurite agar or specially enriched Loeffler, Hoyle, Mueller, or Tinsdale medium.
    • Isolation of C diphtheriae from close contacts may confirm the diagnosis, even if results of cultures on specimens taken from the patient are negative.
    • After C diphtheriae has been isolated, determine the biotype: gravis, mitis, or intermedius (substrain).
  • Toxigenicity testing is also performed.
    • Perform toxigenicity testing using the Elek test to determine if the C diphtheriae isolate produces toxin.
    • Toxigenicity tests are not readily available in many clinical microbiology laboratories; send isolates to a reference laboratory with personnel proficient in performing the tests. The state health department or Centers for Disease Control and Prevention (CDC) can provide information on laboratories that offer this test (few laboratory staffs have the capability to test antibody levels).
    • Measurement of the patient's serum antibodies to diphtheria toxin before administration of antitoxin may help assess the probability of the diagnosis of diphtheria.
    • If antibody levels are low, diphtheria cannot be excluded, but if levels are high, C diphtheriae is less likely to produce serious illness.
Next

Other Tests

Although no other tests for diagnosing diphtheria are commercially available, the CDC can perform a polymerase chain reaction (PCR) test on clinical specimens to confirm infection with a toxigenic strain.

  • The PCR test can detect nonviable C diphtheriae organisms from specimens taken after antibiotic therapy has been initiated.
  • Contact the state health department to report a suspected case and to arrange laboratory testing.
  • Although PCR results for the diphtheria toxin, as performed by the CDC diphtheria laboratory, provide supportive evidence for the diagnosis, data are not yet sufficient for PCR results to be accepted as a criterion for laboratory confirmation.
  • At present, a diagnosis of diphtheria should be classified as probable in a patient with positive results to PCR testing but in whom the organism was not isolated, histopathologic diagnosis has not been made, and no epidemiologic link can be made to a patient with laboratory-confirmed diphtheria.
  • When collecting specimens for culture, obtain additional clinical specimens for PCR testing at the CDC. Because isolation of C diphtheriae is not always possible (many patients have already received antibiotics for several days by the time a diphtheria diagnosis is considered), the PCR test can provide additional supportive evidence for the diagnosis of diphtheria.
  • The PCR assay allows detection of the diphtheria toxin gene (TOX).
  • Clinical samples (swabs, pieces of membrane, biopsy tissue) can be transported to the CDC with cold packs in a sterile empty container or in silica gel sachets. For detailed information on specimen collection and shipping and to arrange PCR testing, the state health department may contact the CDC diphtheria laboratory at (404) 639-1730 or (404) 639-4057.
  • Send all isolates of C diphtheriae, from any body site (respiratory or cutaneous), whether toxigenic or nontoxigenic, to the CDC diphtheria laboratory for reference testing. Clinical specimens should be sent to the CDC diphtheria laboratory for PCR testing. To arrange for specimen shipment, contact the state health department.
Previous
 
 
Contributor Information and Disclosures
Author

Cem S Demirci, MD Consulting Staff, Division of Endocrinology/Diabetes, Connecticut Children's Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Walid Abuhammour, MD, MBA, FAAP Professor of Pediatrics, Michigan State University College of Medicine; Director of Pediatric Infectious Disease, Department of Pediatrics, Al Jalila Children's Hospital

Walid Abuhammour, MD, MBA, FAAP is a member of the following medical societies: American Medical Association, Infectious Diseases Society of America, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur;Astra Zeneca;Novartis<br/>Consulting fees for: Sanofi Pasteur; Novartis; Merck; Astra Zeneca.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Ashir Kumar, MD, MBBS FAAP, Professor Emeritus, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine

Ashir Kumar, MD, MBBS is a member of the following medical societies: Infectious Diseases Society of America, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

References
  1. Lai J, Fay KE, Bocchini JA. Update on childhood and adolescent immunizations: selected review of US recommendations and literature: part 2. Curr Opin Pediatr. 2011 Aug. 23(4):470-81. [Medline].

  2. Dittmann S, Wharton M, Vitek C, et al. Successful control of epidemic diphtheria in the states of the Former Union of Soviet Socialist Republics: lessons learned. J Infect Dis. 2000 Feb. 181 Suppl 1:S10-22. [Medline].

  3. Golaz A, Hardy IR, Strebel P, et al. Epidemic diphtheria in the Newly Independent States of the Former Soviet Union: implications for diphtheria control in the United States. J Infect Dis. 2000 Feb. 181 Suppl 1:S237-43. [Medline].

  4. Oyo-Ita A, Nwachukwu CE, Oringanje C, Meremikwu MM. Interventions for improving coverage of child immunization in low- and middle-income countries. Cochrane Database Syst Rev. 2011 Jul 6. CD008145. [Medline].

  5. Swart EM, van Gageldonk PG, de Melker HE, van der Klis FR, Berbers GA, Mollema L. Long-Term Protection against Diphtheria in the Netherlands after 50 Years of Vaccination: Results from a Seroepidemiological Study. PLoS One. 2016. 11 (2):e0148605. [Medline].

  6. Lurie P, Stafford H, Tran P. Fatal respiratory diphtheria in a U.S. traveler to Haiti--Pennsylvania, 2003. MMWR Morb Mortal Wkly Rep. 2004 Jan 9. 52(53):1285-6. [Medline].

  7. Januszkiewicz-Lewandowska D, Gowin E, Bocian J, Zając-Spychała O, Małecka I, Stryczyńska-Kazubska J, et al. Vaccine-Derived Immunity in Children With Cancer-Analysis of Anti-Tetanus and Anti-Diphtheria Antibodies Changes after Completion of Antineoplastic Therapy. Pediatr Blood Cancer. 2015 Dec. 62 (12):2108-13. [Medline].

  8. Kretsinger K, Broder KR, Cortese MM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep. 2006 Dec 15. 55:1-37. [Medline]. [Full Text].

  9. Murphy TV, Slade BA, Broder KR, et al. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008 May 30. 57:1-51. [Medline]. [Full Text].

  10. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine (Tdap) in Pregnant Women and Persons Who Have or Anticipate Having Close Contact with an Infant Aged 1111111111MMWR Morb Mortal Wkly Rep</i>. 2011 Oct 21. 60:1424-6. [Medline].

  11. Additional recommendations for use of tetanus toxoid, reduced-content diphtheria toxoid, and acellular pertussis vaccine (Tdap). Pediatrics. 2011 Oct. 128(4):809-12. [Medline].

  12. Broder KR, Cortese MM, Iskander JK, et al. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006 Mar 24. 55(RR-3):1-34. [Medline]. [Full Text].

  13. AAP. Diphtheria. Committee on Infectious Disease. The Red Book. 26th ed. American Academy of Pediatrics; 2003. 263-6.

  14. Boughton B. Diphtheria Vaccine Administered in the Thigh Appears Safer. Medscape Medical News. Jan 14 2013. Available at http://www.medscape.com/viewarticle/777585. Accessed: March 18, 2013.

  15. Chen RT, Broome CV, Weinstein RA, et al. Diphtheria in the United States, 1971-81. Am J Public Health. 1985 Dec. 75(12):1393-7. [Medline].

  16. Farizo KM, Strebel PM, Chen RT, et al. Fatal respiratory disease due to Corynebacterium diphtheriae: case report and review of guidelines for management, investigation, and control. Clin Infect Dis. 1993 Jan. 16(1):59-68. [Medline].

  17. Galazka A. The changing epidemiology of diphtheria in the vaccine era. J Infect Dis. 2000 Feb. 181 Suppl 1:S2-9. [Medline].

  18. Hodes HL. Diphtheria. Pediatr Clin North Am. 1979 May. 26(2):445-59. [Medline].

  19. Jackson LA, Peterson D, Nelson JC, Marcy SM, Naleway AL, Nordin JD, et al. Vaccination site and risk of local reactions in children 1 through 6 years of age. Pediatrics. 2013 Feb. 131(2):283-9. [Medline].

  20. Kulkarni PS, Sapru A, Bavdekar A, Naik S, Patwardhan M, Barde P, et al. Immunogenicity of two diphtheria-tetanus-whole cell pertussis-hepatitis B vaccines in infants: A comparative trial. Hum Vaccin. 2011 Sep 1. 7(9):941-4. [Medline].

  21. Lewis LS, Hardy I, Strebel P, et al. Assessment of vaccination coverage among adults 30-49 years of age following a mass diphtheria vaccination campaign: Ukraine, April 1995. J Infect Dis. 2000 Feb. 181 Suppl 1:S232-6. [Medline].

  22. Long SS. Diphtheria. Behrman RE, Kliegman R, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. WB Saunders Co; 2000. 817-20.

  23. Long SS, Pickering LK, Prober CG. Corynebacterium diphtheriae. Principles and Practice of Pediatric Infectious Diseases. Churchill Livingstone; 1997. 861.

  24. Lubran MM. Bacterial toxins. Ann Clin Lab Sci. 1988 Jan-Feb. 18(1):58-71. [Medline].

  25. Mattos-Guaraldi AL, Moreira LO, Damasco PV. Diphtheria Remains a Threat to Health in the Developing World- An Overview. Mem Inst Oswaldo Cruz, Rio de Janeiro. 2003. 98(8):987-93.

  26. McMillan JA, Feigin RD. Diphtheria. McMillan JA, Warshaw JB, DeAngelis CD, eds. Oski's Pediatrics: Principles and Practice. 3rd ed. Wolters Kluwer Co; 1999. 961-4.

  27. Prospero E, Raffo M, Bagnoli M, et al. Diphtheria: epidemiological update and review of prevention and control strategies. Eur J Epidemiol. 1997 Jul. 13(5):527-34. [Medline].

Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.